Casper Vision Center Medical History Questionnaire
Today’s Date ___/____/____
Name: ______________________________________________ Home phone: _______________ Cell Phone: _________________
Mailing Address: _____________________________________ Work Phone: ______________ Occupation: ___________________
City:______________________ State:______ Zip:___________ Employment Status: Full Time / Part Time / Student / Unemployed / Retired
Birth Date _______ / _______ / _______
Social Security # ________ - _____ - ________
Gender: Male / Female
In an effort to make your medical records readily accessible to you please provide your current email address.
Email address : _______________________________________________________________________________________________
Last Blood Pressure: _____/_____
Height ___________ Weight ____________
This information is required as a standard of practice to calculate body mass index (BMI) as certain ocular conditions are more prevalent
with a higher BMI.
Marital Status: Married / Single / Divorced / Widowed
Spouse’s Name: ______________________________________
Race: American Indian / Asian / African American / Hispanic / Native Hawaiian or other Pacific Islander / White (European) / __________
Ethnicity: Hispanic / Native Hawaiian or other Pacific Islander / Non-Hispanic
Preferred language: English / Spanish
Medical Doctor: _______________________________ Last Medical exam: _____________ Last Eye Exam: __________________
Medical Insurance / Policy Holder / Social Security #: ______________________/_________________________/_______-____-______
Vision Insurance / Policy Holder/ Social Security #: ______________________/_________________________/_______-____-_______
Policy Holder’s Birth Date ______/_______/______
Parent / Guardian (if applicable):___________________________________
Medical History / Review of Systems
__________
____________________________________________________________________________________________________________
Are you pregnant and / or nursing?
Do you currently, or have you ever had any problems in the following area: (If yes please circle and explain)
1. CONSTITUTIONAL
Fever, Weight Loss / Gain, Other
2. INTEGUMENTARY
Skin disorders
3. NEUROLOGICAL
Headaches, Migraines, Seizures, Weakness, Paralysis
4. ENDOCRINE
Thyroid, Pituitary, Adrenal, Other
5. EARS, NOSE, THROAT
Hearing loss, sinus problems, Chronic cough, Dry throat /
mouth
6. RESPIRATORY
Asthma, Chronic Bronchitis, Emphysema, Other
7. VASCULAR / CARDIOVASCULAR
Diabetes, Vascular disease, High blood pressure, Heart
disease, Irregular heart beat, Other
8. GASTROINTESTINAL
GERD, Diarrhea, Stomach pain, Vomiting, Other
9. GENITOURINARY
Urinary problems, Kidney disease, STD, Other
10. MUSCULOSKELATAL
Rheumatoid arthritis, Muscle pain, Joint pain, Other
11. HEMATOLOGIC / LYMPHATIC
Blood disorders, Leukemia, Anemia, Other
12. ALLERGIC / IMMUNOLOGIC
Seasonal allergies, Other
13. PSYCHIATRIC
Depression, Anxiety, Other
14. OCULAR (eyes)
Loss of Vision, Blurred Vision, Distorted Vision / Halos,
Double Vision ,Lazy eye / Crossed eye, Drooping of
Eyelid, Cataracts, Glaucoma, Retinal Disease, Flashes /
Floaters, Dryness, Redness, Itching, Burning, Excess
Tearing, Glare / Sensitivity to Light, Eye Pain ,Chronic
Infection of Eye/Lid, Eye Injury or Surgery , Other
► Please turn form over and complete side two◄
EXPLANANTION
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List all major injuries, surgeries and / or hospitalizations you have had: __________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Do you wear glasses?
Do you wear contact lenses?
If yes, check type of contact lens
Social History
Rigid
Soft
Other
What brand of soft contact lenses are you wearing? _______________
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Yes, I would prefer to discuss my Social History information directly with my doctor. (Check Box)
Do you drive?
If yes, do you have visual difficulty when driving?
If yes, please describe:
____________________________________________________________________________________________________________
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
If yes, type / amount / how long: __________________________________________
If yes, type / amount / how long: ________________________________________________
If yes, type / amount / how long: ______________________________________________
Have you ever been exposed to or infected with:
Gonorrhea
Hepatitis
HIV
Syphilis
Family History
Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions:
DISEASE / CONDITION
NO
YES
?
RELATIONSHIP TO YOU
Blindness
Eye turn / Crossed eye
Glaucoma
Macular degeneration
Retinal Detachment / Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other ____________________
This space is provided for you to list any condition not listed or comments that you think the doctor should be aware of.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PAYMENT POLICY:
The exam fee is to be paid the day of the exam. The balance is due
when the glasses or contact lenses are dispensed.
Referred By: __________________________________________________________________
**Unless specified to our receptionist, a text message will automatically be sent as a reminder for any future office visits scheduled.**
Patient’s / Guardian’s Signature _________________________________________________________
Date _________________
Doctor’s signature ____________________________________________________________________
Date _________________